Failure to Investigate and Control Scabies Outbreak
Penalty
Summary
The facility failed to properly investigate, recognize, isolate, track, trend, and treat a scabies outbreak according to current standards of practice for five residents in a sample of thirteen reviewed for infection control. Multiple residents developed rashes over a period of months, with documentation in CNA shower sheets, skin checks, and progress notes indicating the presence and spread of rashes, itching, and scratching. Despite these ongoing symptoms, there was a lack of timely and coordinated investigation into the cause of the rashes, and no consistent use of diagnostic skin scrapings to confirm scabies in residents, even as the outbreak spread among both residents and staff. Residents affected had significant medical histories, including dementia, Parkinson's disease, hemiplegia, diabetes, and other chronic conditions, and many were dependent on staff for activities of daily living. The documentation shows that rashes were noted repeatedly on various body parts, and anti-pruritic medications and topical creams were ordered and applied. However, the facility did not implement appropriate isolation or infection control measures in a timely manner, and there was no systematic tracking or trending of the outbreak in the infection control log. Staff interviews revealed that concerns about scabies were raised for months, but administration attributed the rashes to other causes, such as laundry soap, and did not act on staff reports or implement recommended infection control practices. The facility's infection prevention and control program required the recording and surveillance of suspected infections, but there was no documentation of monitoring or tracking the affected residents' rashes. The outbreak was only recognized after a staff member was diagnosed with scabies by a dermatologist, at which point the facility treated all residents and staff. Prior to this, there was no evidence of isolation, systematic investigation, or notification of public health authorities as required by guidelines. The failure to follow established protocols for early detection, confirmation, and containment of scabies resulted in ongoing transmission among residents and staff.